Play has been recognized as an essential component to children«SQ»s healthy development. Schools of play therapy differ philosophically and technically, but they all embrace the therapeutic and developmental properties of play. This case report is an illustration of how a 6-year-old child with emotional disorder was facilitated to express concerns in child-centered play therapy. The paper discusses the therapist«SQ»s narration of the child«SQ»s play.

Child-centered play therapy (CCPT) stemmed from Virginia Axline's [1] research with young children. Her work established play therapy as an effective treatment modality for children. [2] CCPT creates an environment in which the child can experience integration and self-direction. [3] Child-centered play therapists provide a safe and nurturing atmosphere with a select group of toys and materials and allow the child to lead with minimal limits. CCPT has been found to be effective in children across a wide range of mental health and behavioral problems. [4],[5],[6] An Indian study demonstrates the effectiveness of play therapy in the treatment of children with emotional disorder. [7]

Case Report

A 6-year-old female child (JP) studying in 1 st standard, from middle socioeconomic status, reported to the hospital with chief complaints of dullness and slowness, decreased interaction for a duration of 3 years and from 3 years of age, and difficulties in reading and writing for a duration of 1 year. The child is the eldest of the two siblings born of non-consanguineous union. Her father aged 35 years was educated up to 9 th standard and was working as a driver. Mother was 28 year old, and was educated up to 5 th standard and was a homemaker. Mother was the primary caretaker of the child. Father was punitive. The child was attached emotionally with mother when compared to father. Her relationship with the younger sibling was friendly, but she felt that arrival of the younger child deprived her parental attention toward her. Till the birth of the second child, she was pampered and caressed by both the parents. Her school admission coincided with the birth of younger sibling. The child was temperamentally slow to warm up. There was nil significant past history of illness.

History of presenting illness

Child was apparently maintaining well till 3½ years of age. She was admitted in school, and gradually her parents noticed that when she returned home, she became dull and was never as active as she was. She remained quite all the time. She was seen to be playing less with her sister, and most of the time, she had engaged in her own play all alone. Parents received complaints from school that she had difficulty in reading and writing. After teaching repeatedly many times, in about 10 min, she used to report forgetting. At school, she was physically punished. She never used to speak up in class when asked to answer. Most of the time, she was alone sitting in a corner, or she used to watch the other kids play and never mingled with them. She did not interact with the other children of her class. She was noticed be doing her activities such as brushing, dressing, etc. very slowly at home. Her appetite was also reportedly decreased. She was refusing to eat food; if given, she was taking longer time to eat, and because of this she was late to school and used to be punished for this. With her younger sibling, she used to play occasionally. She reduced her interaction at home, with her parents, especially father, and younger sibling. She was not allowed to go out and play; if she did, then she was punished by father. Fearing father, she stayed back at home.

Clinical interview

General temperament as observed indicated good attention and concentration. She was less sociable and took time to adjust to a new situation. Child's attention could be aroused and sustained. Eye contact could be initiated, but was not sustained. She used to be constantly looking down while speaking, and sometimes only nodded her head to respond. Her speech in terms of tone, tempo, and volume was less. She looked dull. Reactivity was present, but her reaction time was rather prolonged. When she was given color pencils to draw, she took them with smile, gradually interacted about the picture, and rapport could be established. The proposed multi-axial diagnosis is: AXIS I - ? Emotional disorder; AXIS II - learning difficulties; AXIS III - average intelligence; AXIS IV - nil; AXIS V - abnormal psychosocial disturbances, punitive parenting, and school stress. [8],[9]

Formulation

The child's difficulties can be understood from the developmental perspective. The child was pampered by both the parents; after the second child was born, attention was diverted to the younger child. This was the time the child was admitted to school. This probably led to anxiety and fear of abandonment from the mother. When she was not able to read and write, like other children, pressure was evident from the teachers who used to punish her sometime. There was some evidence for feelings of anxiety as well as anger toward parents, which was suppressed, and this resulted in withdrawn behavior and academic difficulties.

Therapy

The child was seen at Child and Adolescent Mental Health Unit (CAMHU), NIMHANS. Client-centered play therapy was planned, and the session was carried out in CAMHU playroom under the supervision of the second author. The child was seen in a playroom consisting of various toys. The session was carried out everyday on an outpatient basis (10 sessions) and was followed by parental psychoeducation. The follow-up with child and parents was done once a month on an outpatient basis (five sessions). The short-term goals were to establish rapport, provide a validating environment, and establish trust, so that the child could open up and improve open communication. Attempts were made to facilitate expression of feelings, needs, and conflicts through play therapy, and finally the plan was to engage parents. The long-term goals were to encourage the mother to continue non-directive play interactions at home and to consider change of school.

Therapeutic process

Initial phase (1-3 sessions)

During this phase, focus was on developing rapport with the child, as the child was extremely fearful to speak. She was taken to a playroom and was allowed freely to explore the play materials. Therapist responded only to child's questions and the child was told that she was free to play. She started playing with the sand and made a doll out of it. The child noticed the cradle and said that she and her sister were made to sleep in cradle. She identified grandpa, grandma dolls, baby dolls, and she cooked, fed them, and put them to sleep. She was fearful about the hanging dolls and made a remark that they looked like devils. She expressed in a sad tone that her mother had not bought her a doll. When it was time to leave, she bargained to play for some more time, but was willing to go when gently reminded. The "inferences" made were as follows. The child was very curious and wanted information; she took initiative in asking instead of doing, indicating "dependence" on the therapist. The session also indicated unhappiness for not providing dolls at home (deprivation). In the next session, she explored all other play items, and went to market to purchase vegetables, started cooking and served food for all. She went to school as a teacher. When she returned, she lit the lantern as she was anticipating devil. She also showed interest in coloring and copying words. The inference derived was that she expressed her likings in household activities and teaching. There was shifting of one activity to another, indicating difficulty in concentration. She was also able to make decisions while playing. On the third day, she involved the "therapists" for the first time she offered her "ladoos" to eat. She continued to play the role of teacher. While sleeping, she took the knife to slit devils. She herself made some sound and made the gesture of cutting the devil. An inference of the session was that the child exhibited increased identification with the mother, and there was expression of fear of devil.

Middle phase (4-8 sessions)

She picked up bangles and said that she was attending wedding along with other dolls. Inference of this session was that the child was more relaxed and did not mention devil. There was more meaningful theme, but she did not pursue it, for example, marriage; there was no mention of rituals, guests, etc. She wanted to do everything by herself, indicative of being burdened with work (identification with the mother). She also accepted the time imposed on her. In the next session, she never asked any questions; she picked up the cylinder, filled water in a vessel, played with sand, and reported that people were traveling. She shifted the house entirely from one corner to the other, saying it was a new house, and made many other smaller houses in the wooden blocks. She lit the lamp, and said that thieves would come; she took a gun and fired at thieves. She involved the therapist as a student and taught her colors and numbers. The inferences were that the child wished for new home and was able to cope with her fear of thieves. Next day, she took a truck and played with it, lifted a boy doll and said that he was a thief and kept it aside. When the therapist reflected that the boy was a thief, she reaffirmed it and fired with pistol, later fired the roof of the house, and said all thieves were gone. She went back to sand, sieved it well, and started cooking again. The inference included that the child expressed aggression toward boy figure. When she felt that she adequately dealt with her fear, she resumed cooking activity and appeared very happy. The activities were mostly cooking and serving different types of food. She went back to school; she wanted the therapist to be a student and expected to greet her, and when greeted, she praised the therapist. The inference was that the there was an expectation from the teacher to treat students well and praise for their good behavior. Her play was largely age appropriate.

Termination phase (9 and 10 sessions)

Termination was planned after nine sessions. In the last session of the play therapy, she explored all objects which she had missed in the other sessions. She cooked, and said since it was the last day, therapist who had been eating less should eat more, and she served more. The child was told that it was time to leave; she looked at the room once with a smile, touched all the dolls and came out. The child was asked about her experiences in the play. She reported that she really enjoyed it and wanted her mother and grandfather to get the dolls to play with her. She was appreciated for her cooperation. She was encouraged to speak about her difficulties with parents. Feedback about inferences was reframed positively to parents. The mother was requested to continue play interactions at home, allowing the child to freely express her emotions and concerns. The parents were also told to respect her and give reward for good behavior. Targets and strategies for learning difficulties were suggested. Importance of extracurricular activities was highlighted. A letter was given to the school teacher explaining the nature of child's problem as well as strategies to deal with her.

Follow-up (five sessions)

After 1 month of termination of the play therapy, the parents reported that there was improvement in the child's communication, activities, and studies. The mother expressed concern over child's reduced food intake. Behavioral techniques for making eating an enjoyable experience were suggested. The child also expressed happiness both at home and school.

Discussion

Play in play therapy can be a means for establishing rapport with children. It helps adults understand children and their interactions and relationships. [10] In this study, play therapy helped the therapist to build relationship with the child and to explore child's likes and dislikes. The child was able to express her identification with the mother and her fear of devils. Over the sessions, she played out her anxieties in school situations and was also able to cope with her fears in an age-appropriate manner. The child had a need to nurture, help others, which probably was not facilitated in her daily life. The play activity gave her ample opportunities to satisfy these needs. Parental counseling emphasized the need to change parenting style while interacting with the child. A study on the effectiveness of play therapy in young children with emotional disorder also highlights these observations. [7] The limitation of the study is that objective pre- and post-evaluation of child's functioning was not carried out. The implication of this study is that play therapy facilitates child's expression of feelings and concerns. The study also suggests that home-based play intervention module can be developed.